Podcast 204 – The Nurse-Led Code with Joe Bellezzo

I am joined again by my good friend, Joe Bellezzo, to discuss the nurse-led code. I've been doing this at my two shops for about a decade. Joe, along with his partners-in-crime Zack Shinar & Chris Ho, have set up a beautiful process for nurse led code management at their hospital, Sharp Memorial in San Diego.

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Hey Scott and Joe, You guys mentioned in the podcast the lack of evidence and clinical outcomes data to support instituting this across the board. You guys also made a very reasonable and cogent argument for changing practice in the absence of clear evidence. I would humbly add, however, that there is preponderance of evidence in the Human Factors literature that would support such an approach to running a code. We know that stress, increases in work load (particularly things that uses a lot of brain power like diagnostic reasoning), and time pressure all result in decreased capacity to effectively process information (decreasing cognitive “bandwidth”). This cognitive overload results in increased errors, lapses in situation awareness, and decreases in prospective memory (remembering to do something in the near future). We also now understand that multitasking is largely a myth and what we end up really doing as rapid task-switching which can also be problematic. Finally, it is become clear that interruptions are also a source of error and lapses in concentration. (NOTE: I’m sure my friends in the human factors world can point out some additional issues as well) Codes, by their very nature, exhibit many of these aforementioned characteristics.… Read more »

Great discussion. I have been implementing some of these ideas with agreeable physicians in the last two years as a bedside ED nurse and I have received great feedback. It is a huge pet peeve of mine when I see an RN code recorder state all too timidly, “that’s two minutes, rhythm check,” followed by silence as physicians discuss the beyond-ACLS problems. A few seconds later, “are we doing a rhythm check?” Can’t handle it. As nurses we have to claim ACLS and own quality CPR, something we can do very well, so that ED physicians can do what they do best during a code. Now transitioning to the NP role, I look forward to advocating for nurse-led codes. Thanks for covering this and empowering nurses to take leadership. Another major barrier: Nurse educators are so overwhelmed with on-boarding new RNs (due to incredibly rapid turnover, 11.2 to 17.2% nationally from 2011 to 2015, see http://bit.ly/2v5bgmH ) that developing training for plans like these take a back seat… Nurse turnover is and will be one of the biggest challenges for urban EDs. So Scott, what barriers did you face with implementation? Do all your physician colleagues do nurse-led codes? John… Read more »

great points!! you’ve touched on the major issue, new nurses and no time to train them. this is why we only ask for the 4 points (the first 4 of the 5 above)–all of which can be briefed in <30 seconds before the patient arrives. Give epi every 5 minutes, tell us 30 sec before rhythm check, announce the rhythm check, and assign nurses to get tasks done. No extensive on-boarding necessary (though it sure would be beneficial). A cheatsheet with those 4 points could easily be made and put on to the code sheets.

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1 year ago

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Sean Seah

Hi Scott and Joe,

I am an Emergency Trained RN practising in Singapore. Thank you for the great podcast and it really spurs my thoughts on this Nurse-led Code. My team and I are trying to get buy in from our nurses on this. Thus, I would like to know what are the positive vibes do your nurses received from co-leading codes with physicians.

Very interesting post. Any thoughts of how this dynamic could play out during in-hospital arrests where the nurses and docs are a) not co-located and b) do not train/simulate together and c) there is often little to no consistent attending oversight? I’ve wondered whether our rapid response nurse team should actually run these codes, rather than an on-call medicine resident who may have little experience in such situations.

I think the RRT nurse should definitely take the helm as mentioned above. The med resident would be filling the System I role, though not as effectively as someone more experienced. And of course the RRT Nurse will likely be spurring most of that system I thinking when the doc forgets/doesn’t yet know.

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1 year ago

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Jem

The RRT nurse would be paralyzed if another code is called in the hospital while trying to lead this one. The question now is who is going to lead? The charge nurse or the nurse taking care of the pt who is currently coding?

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1 year ago

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Jem

I have always asked myself why nurses cannot apply ACLS and lead the code in the hospital and now this is the answer. Have you heard about ths being used in ICU?

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1 year ago

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Steve

I’m interested that you mentioned delaying defibrillation to place an arterial line. Isn’t timely defibrillation one of the only things that has evidence to improve outcomes? I feel like that should be prioritized over almost anything else, especially an arterial line. If you are cannulating for ECMO, I could understand not defibrillating but not just for an a-line

We are going live with this at UVM in September! There’s a lot of excitement about this in our department from both the nurses and physicians. It’s great to hear how other people are approaching this. Thanks!

do you folks have a formal protocol? if so, would you consider linking

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1 year ago

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Shane

This isn’t describing a nurse-led code. A(C)LS trains any person to call out the next guideline steps, as you are having the nurse do, which is an excellent idea to cognitively offload the person who is actually leading the arrest – which is actually the physician, as you repeatedly reaffirm during the podcast. Nice branding (I’m sure ‘nurse-led’ really helps with some CRM and having buy-in from the nursing staff) but the name is actually misleading. Your described technique is well-known to pilots, who will often have the First Officer fly the plane in an emergency, so that the Captain can concentrate on the more complex management, without being bogged down in the simpler mechanical task of manipulating the aircraft. DÓI: nurse on cardiac arrest teams for 10 years (led (in the true sense) plenty of arrests as a nurse, until a superior mind could provide higher-level guidance), now qualified as a physician, and still leading arrests! I think you have taken the phraseology too far – to the point where CRM will suffer as a consequence of not understanding who the leader actually is (I was certainly confused, until I heard during your podcast that the nurse wasn’t actually… Read more »

Shane-think we agree on everything but semantics. Now, I love arguing semantics and could do it for hours. Not sure there is much of a quibble here though. The term “leader” can mean many things, I would say a majority of “leaders” in our daily lives are carrying out rote roles. In our system there is a physician code-leader and a nurse code-leader, they Co-lead. There is no ambiguity or conflict in those 2 roles, they work in concert with each other and the team. I think the only place the semantics break down is if we have a preexisting autocratic need for there to be only 1 leader.